252

CASE REPORT

Acute caused by both acute and epididymitis

Hajime Nakatani, Shinichi Hamada, Toyotake Okanoue, Akihiro Kawamura, Yuichiro Inoue*, Shinya Yamamoto**, Takashi Chikai**, Makoto Hiroi***, and Kazuhiro Hanazaki****

Department of Surgery, *Department of Urology, and **Department of Anesthesiology, Kubokawa Hos- pital, Kochi, Japan ; ***Laboratory of Diagnostic Pathology, and ****Department of Surgery, Kochi Medical School, Kochi University, Kochi, Japan

Abstract : Acute appendicitis often presents as right lower quadrant (RLQ) pain, severe tenderness at the point of McBurny or Lanz, and Blumberg’s sign. Scrotal events with ap- pendicitis are very rare. In our case, a 63-year-old Japanese man presented with severe RLQ pain and high fever. revealed severe tenderness (including both points of McBurny and Lanz) and Blumberg’s sign. The scrotum was slightly swol- len and showed local heat with severe testicular pain. Abdominal computed tomography revealed in a pelvic space and the right side of the spermatic cord was swollen. Emergency operation was performed and the final diagnosis was catarrhal appendicitis and acute epididymitis. This is the first report of acute appendicitis concomitant with acute epididymitis. J. Med. Invest. 58 : 252-254, August, 2011

Keywords : right lower quadrant pain, acute appendicitis, epididymitis,

INTRODUCTION CASE REPORT

Acute appendicitis is one of the most common In November 2009, a 63-year-old Japanese man acute abdominal diseases requiring emergency op- presented with RLQ pain that had been continuous eration. The diagnosis is based on well-established for a night. Past history included poliomyelitis in clinical symptoms and basic radiological examina- infancy. Physical examination showed severe ten- tion (1). Epididymitis is the most common cause of derness at the points of both McBurny and Lanz testicular pain, and usually shows acute onset (2). with Blumberg’ sign, and a swollen scrotum with We present herein a case of concomitant acute ca- testicular pain. Body temperature was 38.3!!.Pe- tarrhal appendicitis and epididymitis with severe ripheral blood leukocyte count was 15,600/mm3 right lower quadrant (RLQ) pain and pelvic ascites. (normal, 4000-9000/mm3) and serum C-reactive protein level was 11.05 mg/dl (normal, 0.00-0.03 mg/dl). Urine sediment test showed a white blood cell count of 10-19/high-power field. Abdominal Received for publication January 14, 2011 ; accepted March 7, computed tomography (CT) revealed swelling of the 2011. spermatic cord on the right side (Fig. 1a, arrow) and Address correspondence and reprint requests to Hajime Nakatani, Department of Surgery, Kubokawa Hospital, Shimantocho, Kochi ascites in the pelvic space (Fig. 1a, arrowhead), but 786-0002, Japan and Fax : +81-880-22-1166. we could not detect a swollen . Ultra- sonography showed a swollen epididymis (Fig. 1b,

The Journal of Medical Investigation Vol. 58 2011 The Journal of Medical Investigation Vol. 58 August 2011 253

Figure 1 : a : CT scan Arrow, spermatic cord ; arrowhead, ascites. b : Ultrasonography shows coronary section. Arrow, epididymis ; arrowhead, testis.

Figure3:Pathological analysis a:!100, b :!400 magnification arrow). Given the above problems, acute appendicitis and acute epididymitis were considered. Appendec- tomy was performed using McBurny’s incision. As- days and testicular pain gradually disappeared cites was serous, but not clear. No surgical drain (Fig. 4). However, the patient unfortunately devel- was used. Pus was observed in the lumen of the oped herpes zoster during hospitalization and thus appendix (Fig. 2, arrow). Pathological analysis re- was not discharged until postoperative day 20. vealed infiltrating leukocytes localized in the mu- cosal layer and exfoliation of the mucosa, so ca- tarrhal appendicitis was diagnosed (Fig. 3a, b). Enterobacter aerogenes was detected in urine, but not in ascites. Cefmetazole (CMZ) was administered as antibiotic for 5 days. Postoperatively, RLQ pain continued for about 4

Figure4:Time course of body temperature, right lower quad- rant pain (RLQ), testicular pain, and concentration of C-reacted protein. X-axis : body temperature (B.T.) Y-axis : postoperative day (P.O.D) Figure 2 : Surgical specimen +++ : severe pain, ++ : moderate pain, + : mild pain Arrow, pus-coated lumen of the appendix. Arrow, cefmetazole administration 254 H. Nakatani, et al. Acute appendicitis with epididymitis

DISCUSSION inflammatory changes. The spermatic cord was swollen on the right side on CT. This swollen sper- We present the first report of concomitant acute matic cord was probably followed by epididymitis. appendicitis and epididymitis. Epididymitis is most Appendectomy was performed on suspicion of ap- often associated with sexually transmitted diseases, pendicitis due to severe symptoms. and the peak incidence is 25 years old. Conversely, Pathological analysis revealed infiltrating leuko- in men over 50 years old, epididymitis is associated cytes localized in the mucosal layer, and exfoliated with urinary tract infection or prostatitis (2). Treat- mucosa was observed so catarrhal appendicitis was ment of epididymitis is with antibiotics, based on diagnosed. After appendectomy, testicular pain and the association with urinary tract infection (2). The RLQ pain continued for 10 days and 4 days, respec- frequency of lower with epididymi- tively. tis is not clarified. During 2005-2010, in our hospi- In conclusion, we encountered a case of acute ab- tal, 17 patients were diagnosed with epididymitis. domen with sever RLQ pain due to acute appendi- Of these, 6 patients diagnosed with epididymitis citis and spermatitis followed by epididymitis. showed lower abdominal pain, localized to the in- guinal region and mild in all cases. In the present case, the patient had severe RLQ REFERENCES pain at McBurny’s and Lanz’s points and testicular pain was severe. Enterobacter aerogenes was grown 1. Akbulut S, Ulku A, Senol A, Tas M, Yagmur Y : in urine culture, but not in ascites. Therefore, we Left-sided appendicitis : Review of 95 published could not confirm the involvement of Enterobacter cases and a case report. W J Gastroenterol 16 aerogenes in this event. Saleem described a case in (44) : 5598-5602, 2010 which a scrotal event occurred following a perfo- 2. Schubert H : Emergency case. Acute testicular rated appendicitis (3). In the present case, as patho- pain. Can Fam Physician 46 : 1289-1290, 2000 logical analysis indicated that the appendicitis was 3. Saleem MM : Scrotal abscess as a complica- not severe, we could not confirm whether there tion of perforated appendicitis : a case report was a relationship between acute appendicitis and and review of the literature. Cases J 1(1) : 165, epididymitis. Inflammatory diseases such as acute 2008 appendicitis or diverticulitis manifest as stranding 4. Lee MW, Kim YJ, Jeon HJ, Park SW, Jung SI, of fat in tissues adjacent to the thickened bowel Yi JG : Sonography of acute right lower quad- wall on CT (4). CT revealed intraperitoneal fluid rant pain : importance of increased intraabdomi- collection in the pelvic space, but fat tissue in the nal fat echo. Am J Roentgenol 192(1) : 174- RLQ of the abdomen and appendix did not display 179, 2009